HAVS Assessment Template

• Site

• Location
  Address

• Full Name of Safety Officer

• Date of Assessment

  Date

HAVS Assessment

• Briefly describe the work activities that require workers to use vibrating tools and equipment.

• Workers exposed to HAVS risks

WORKER

• Full Name

• Source of Vibration

TOOL

• Select vibrating tool or equipment

  Select Concrete breaker Hammer drill Grinder Disc Cutter Sander Chipping hammer Needle gun Other

  • Concrete breaker
  • Hammer drill
  • Grinder
  • Disc Cutter
  • Sander
  • Chipping hammer
  • Needle gun
  • Other

• Specify vibrating tool or equipment

• Vibration Magnitude

• Trigger Time

• Exposure Points

• Exposure Level

  High Priority

  Medium Priority

  Low Priority

• Select control of exposure

  Select Eliminated vibration exposure Applied time limit Reduced vibration exposure Applied job rotation Trained worker Replaced tool or equipment Repaired tool or equipment Other

  • Eliminated vibration exposure
  • Applied time limit
  • Reduced vibration exposure
  • Applied job rotation
  • Trained worker
  • Replaced tool or equipment
  • Repaired tool or equipment
  • Other

• Specify control of exposure

Completion

• Additional Recommendations

• Full Name and Signature of Safety Officer

  Sign